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DEVELOPMENT OF A FORMAL FRAMEWORK FOR USABLE OPERATIONS SUPPORT IN E-HEALTH BASED SYSTEMS Ph.D FINAL DEFENSE BY IKHU-OMOREGBE NICHOLAS (CU03GP0021) DEPARTMENT OF COMPUTER AND INFORMATION SCIENCES, COVENANT UNIVERSITY, OTA, AFRICA EXAMINERS Dr. Ayo C. K. - Chief Examiner Dr. Ehikioya S. A. - Supervisor Dr. Ayo C.K. - Co-Supervisor Prof. Katende J. - College Examiner Dr. Adebiyi E. F. - Departmental Examiner Prof. Sofulowe A. B - External Examiner 5-May-17 PhD Defense - CIS 2 CONTENTS INTRODUCTION STATEMENT OF THE PROBLEM AIM/OBJECTIVES METHODOLOGY RESULTS/DISCUSSIONS SUMMARY AND CONCLUSION 5-May-17 PhD Defense - CIS 3 INTRODUCTION Information and Technologies have been introduced in different dimensions of health care (Intel 2003, infoDev & Alcatel 2005). OSS solution for e-Health takes advantage of the state-of-arts information technology to address health care enterprise-wide needs and requirements to reduce cost, provide reliable, flexible, mobile timely and secure health care delivery to patients by care provider and centers. 5-May-17 PhD Defense - CIS 4 STATEMENT OF THE PROBLEM Although the health care community is embracing mobile technology and realizing its benefits, mobile computing usage is still being faced with significant number of obstacles such as (Gregg M., 2005): Ease of use (usability) Confidentiality of mobile data and the management of newly mobile health care workers 5-May-17 PhD Defense - CIS 5 STATEMENT OF THE PROBLEM The level of an e-Health based system’s usability does not only influence the users acceptance of the system but may also greatly influence the diagnosis and treatment processes in a health care centre. The usability of OSS is vital since its issues in software products cannot be resolved without major changes to the software architecture [Roger P., 2005]. This thesis provides answers to usability issues in mobile devices for e-Health based systems. 5-May-17 PhD Defense - CIS 6 USABILITY OF MOBILE HEALTH CARE DEVICES 5-May-17 PhD Defense - CIS 7 AIM/OBJECTIVES OF THE STUDY Provide a formal framework for usable operations support for e-Health based systems . (AIM) 1. Provide a formal framework for e-Health based systems 2.Provide a robust architecture which ensures that best clinical practices are followed in a health care centre in the administration of patient care. 3.Provide a support system that distributes patient medical information amongst medical practitioners in a healthcare environment across mobile devices. 4.Implement some of the functionalities in an e-Health system to empirically validate the usability of the operations support system in the application domain. 5-May-17 PhD Defense - CIS 8 METHODOLOGY- OBJECTIVE 1 To assure the quality, acceptability, and usability of the system, we used OCL and the Unified Modeling Language (OMG 2003, CMU/SEI 2004) for the specification, analysis, design, and verification of the system’s functionalities. 5-May-17 PhD Defense - CIS 9 Introduction-Definition The Encyclopedia of Software Engineering defines Formal methods as “ A mathematical based technique for describing system properties” 5-May-17 PhD Defense - CIS 10 Definition Formal Methods "refers to mathematically rigorous techniques and tools for the specification, design and verification of software and hardware systems”. (Ricky W. Butler, 2001, NASA) 5-May-17 PhD Defense - CIS 11 Importance of Formal Methods System specification may contain contradictions, ambiguities, incomplete statements etc. When used well, a formal method should yields specifications that have significant advantages over natural language and variety of graphical notation. 5-May-17 PhD Defense - CIS 12 Importance (Cont.) A formally verified system can be used unto greater reliability. Thus the use of formal technique helps to achieve a high degree of confidence that a system has conformed to its specifications This is particularly significant in the health care domain We modeled the system as follows: 5-May-17 PhD Defense - CIS 13 Hospital/Clinic -Name : char -Idno : int -Address : string +AddClinic() +DelClinic() +UpdateClinic() 1 Patients Medical Personnel -StfId -Name -Address -ClinicID -Status -Tel +Add() +Update() +View() 1..1 -PatId -Name -Address1 -Age -Status -Tel Out-patient In-Patient 1 1 Nurse 1 Doctor Pharmacist 1 Lab Technician 1 Specialist Rooms Appointments +AddAppt() +FindAppt() +UpdateAppt() +ViewDgns() Diagnosis Medications Lab Test +AddDgns() +UpdateDgns() +ViewDgns() +AddMed() +UpdateMed() +ViewMed() +AddTest() +UpdateTest() +ViewTest() 0..1 0..1 Surgery Rights -RoomID -Charges 0..1 0..1 0..1 0..1 Medical Record -PatientID -Date -Diagnostic Info -Test Result -Encounter +viewAppt() +ViewLab() +ViewPatient() +ViewMed() +FindPatient() 5-May-17 PhD Defense - CIS 14 Use Cases Patient Treatment Use Case Retrieve patient's info Book appointment Nurse Patient Take clinical measurements «uses» Doctor Diagnose and treat «extends» «extends» Perform lab test «extends» Refer case Specialist medication Lab Technologist Pharmacist 5-May-17 PhD Defense - CIS 15 Sequence Diagram CareGiver Mobile Device WAP Gateway WebServer Servlet Engine Database Server RequestInfo() Connect through WAP Authenticate() Activate Servlet ExecuteQuery() RetrieveInfo() WMLContent Response Info Send through channel DisplayInfo() 5-May-17 PhD Defense - CIS 16 State Chart Visit clinic Appointment Treat patient Under treatment Medication Clinical measurement (pre-treatment) Diagnosis H X Continue treatment Suspend treatment Lab test 5-May-17 Pay bill PhD Defense - CIS 17 Collaboration Diagram make diagnosis() prescribe drugs() request treatment() performs surgery refer Patient Doctors Specialist request test request test Nurse retrieve patient records () take clinical measurements() schedule appointment() 5-May-17 Pharmacist dispense drug() PhD Defense - CIS Lab Technologist performs test() 18 Deployment Diagram MOBILE DEVICES -802.11b -WIRELESS LAN Doctor’s Point of Access * * WAP, SMS SERVER -TCP/IP * * APACHE WEB SERVER DBSERVER -ODBC-JDBC * PATIENT DB E-HEALTH APP. 5-May-17 PhD Defense - CIS * 19 WAP/UML Extension <application> EhealthDatabases <<deliver> <<deck>> PatientRecord <<card>> UpdatePatientPage <<next>> 5-May-17 PhD Defense - CIS <<previous>> 20 An Overview of Object Constraints Language (OCL) OCL was developed as a modeling language within the IBM insurance division. OCL is a pure expression language, an OCL expression is guaranteed to be without side effects. When an OCL expression is evaluated, it simply returns a value. It cannot change anything in the model. 5-May-17 PhD Defense - CIS 21 An Overview of OCL (Cont.) Fully type language - Boolean, Integer, Real and String as basic types - Collection such as Sets, Sequences and Bags are included -OCL expressions can be verified 5-May-17 PhD Defense - CIS 22 Where to Use OCL To specify invariant on classes and types in the class model To describe pre and post condition on operations and methods To describe Guards As a navigation language To specify constraints on operation 5-May-17 PhD Defense - CIS 23 Notations All OCL statements, must take place within a context. This might be a class or a use case. The statement themselves can be invariant, pre condition or post condition 5-May-17 PhD Defense - CIS 24 Invariant , Pre-Condition An invariant is a property that must remain true throughout the life of a model element, such as an object A pre-condition is property that must be true before a particular part of the system is executed. This can be applied to operation during design and implementation and to use cases during analysis. 5-May-17 PhD Defense - CIS 25 Post-Condition , Constraints A post condition is something that must be true after particular part of the system is executed, if that execution was legal A constraint is a rule that allows you to specify some limits on a model (Warmer and Klepper, 1999) describe it as a restriction on one or more values of (part of) an object-oriented model system. 5-May-17 PhD Defense - CIS 26 Patient Requirements Specification: Every patient is unique context clinic inv: Patient->forAll(p1,p2/p1<>p2 implies p1.pid <> p2.pid) 5-May-17 PhD Defense - CIS 27 Patient Requirements Specification: To add a new patient the patient must not exist before. context patient::regpat(p:patient) pre: not patient->include (p) post: patient->size=(patient@pre->size ) +1 and patient->include (p) 5-May-17 PhD Defense - CIS 28 Doctor Requirements Specification: Each Staff has permissible operations to perform context medicalpersonnel inv: Self.medicalpersonel.staffid.right->exist(p/ p.diagnose() or p.addrecords () or p.updatepatientrecord() or p.viewmedication() implies medicalpersonnel.asType(doctor)) 5-May-17 PhD Defense - CIS 29 Pharmacist Requirements Specification: Each Staff has permissible operations to perform context medicalpersonnel inv: self.medicalpersonel.staffid.right->exist(p/ p.viewmedication() or p.dispense ( ) ) implies medicalpersonnel.asType(pharamacist) 5-May-17 PhD Defense - CIS 30 Medication-Allergic Requirements Specification: The systems keep track of drugs a patient is allergic to: context medication::AllergicAdd(d:drug) pre: not allergic ->include (d) post: allergic ->include (d ) and allergic ->size =(allergic@pre ) + 1 5-May-17 PhD Defense - CIS 31 Administrator Requirements Specification: Each Staff has permissible operations to perform context medicalrecords inv: self.medicalpersonel.staffid.right->exist (p/p.create( ) or p.delete()) implies medicalpersonnel.asType(administrator) 5-May-17 PhD Defense - CIS 32 Appointment Requirements Specification: No two patients will be directed to the same doctor at the same time on the same day. context Appointment inv: not(Self.appointment-> exist(x,y/(x.doctor=y.doctor) and (x.time=y.time) and (x.date=y.date)) 5-May-17 PhD Defense - CIS 33 Appointment Requirements Specification: A request for an appointment to see a doctor must not be for a date earlier that the date of registration of patient at the clinic. context appointment inv: Self.dateofrequest.after(registrationdate) 5-May-17 PhD Defense - CIS 34 Booking Appointment context Appointment::addapt (patId, stafid, startTime, endTime, date) pre: startTime <endTime post: duration=endTime – startTime >0 startTime = preStart + duration prevEnd = startTime 5-May-17 PhD Defense - CIS 35 The User Requirements Specification: The password and username of every user of the system must be unique. context registeredUsers inv : not(self.users->exists(a,b/a.username= b.username ) and (a.password =b.password)) 5-May-17 PhD Defense - CIS 36 OCL CHECKER 5-May-17 PhD Defense - CIS 37 ACCOMPLISHING OBJECTIVE 2 Provide a robust architecture which ensures that best clinical practices are followed in a health care centre in the administration of patient care. 5-May-17 PhD Defense - CIS 38 SOFTWARE ARCHITECTURE Security and Authentication Support Service Presentation Layer Cell Phone Smart Phone Documentation Support Service View and Report Service USERS INTERFACE Web Server WAP Gateway Apache Server SMS, MMS Server Middleware Data Access and Update Support Service Pharmacy and Billing Support Service Diagnostic Support Service Laboratory Test Support Service Patient Medical Record Support Service CARE SUPPORT SERVICES Data Layer 5-May-17 Logon DB Lab. Test DB Medication DB PhD Defense - CIS Patient DB 39 SOFTWARE ARCHITECTURE A 3-tiered C/S architecture consisting of client interface, middle-tier, and database repository Components of the client =SASS, DSS, VRS Server-side processing carter for resources constraints Middle-tier contains most of the application logic and translate client request into database queries =DAUSS, PMRSS, DSS, PBSS, LTSS The data layer is responsible for the storage, retrieval, maintenance and integrity of data Communication between the application server and database is performed by the JDBC-ODBC bridge 5-May-17 PhD Defense - CIS 40 HARDWARE ARCHITECTURE SmartPhone Terminal Firewall E-Health Database Server Firewall AP Web server E-Health Server Laptop Database PDA 5-May-17 A Medical Diagnostic Device PhD Defense - CIS 41 HARDWARE ARCHITECTURE Consist of complete range of robust high performance clients and servers Clients system include, PDAs, Cell Phones, other hand-held medical devices The servers are used to maintain connectivity to enterprise resources Servers provide, real-time access to point of care data base Firewalls are set to filter all network traffic moving in an out the e-Health system 5-May-17 PhD Defense - CIS 42 ACCOMPLISHING OBJECTIVE 3 Provide a support system that distributes patient medical information amongst medical practitioners in a healthcare environment across mobile devices. 5-May-17 PhD Defense - CIS 43 PATIENT’S SUPORT 5-May-17 PhD Defense - CIS 44 WELCOME PAGE 5-May-17 PhD Defense - CIS 45 ADMINISTRATOR’S SUPPORT 5-May-17 PhD Defense - CIS 46 PHARMACIST’S SUPPORT SERVICE 5-May-17 PhD Defense - CIS 47 DOCTOR’S SUPPORT SERVICE 5-May-17 PhD Defense - CIS 48 MS ACCESS DATABASE 5-May-17 PhD Defense - CIS 49 ACCOMPLISHING OBJECTIVE 4: Implement some of the functionalities in an e-Health system to empirically validate the usability of the operations support system in the application domain. 5-May-17 PhD Defense - CIS 50 DISCUSSIONS/RESULTS 5-May-17 PhD Defense - CIS 51 USABILITY MEASUREMENT ISO ( 9241) Definition The “extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use” 5-May-17 PhD Defense - CIS 52 USABILITY MEASUREMENT Users – Medical Practitioners - Doctors - Nurses - Lab Technologist - Pharmacist - IT Professional - Patient ( Students + Others ) - Goal – Improve Health Care Delivery - Context – Clinic (Health Care Setting) 5-May-17 PhD Defense - CIS 53 USABILITY ATTRIBUTES Effectiveness: -The accuracy and completeness with which specified users can achieve specified goals in particular environment Efficiency: The resources expended in relation to the accuracy and completeness of goals achieved 5-May-17 PhD Defense - CIS 54 USABILITY ATTRIBUTES Satisfaction: The “freedom of discomfort, and positive attitude to the use of the product” The comfort and acceptability of the work system to its users and other people affected by its use 5-May-17 PhD Defense - CIS 55 Usability Framework We used the following seven metrics to represent the usability dimensions of the application. Completion Time Easy to Learn Effective Support Error Recovery Comfortable Easy to Use Satisfaction 5-May-17 PhD Defense - CIS 56 USABILITY EVALUATION Data - - Collection Technique – Questionnaires were administered to users after interacting with the system 150 Responses were received and analyzed The response format used a five-point, Likert-type scale 5-May-17 PhD Defense - CIS 57 DATA ANALYSIS Usability studies suggest that system with “good usability” typically have a mean rating of 4 on a 1-5 scale rating and 5.6 on a 1-7 scale (Jeff Sauro et al, 2005) The 5-May-17 mean rating as follows: PhD Defense - CIS 58 Values of Usability Attributes Completion Time = 4.52 Easy to Learn = 4.53 Effective Support = 4.31 Error Recovery 4.55 Comfortable = 4.59 Easy to Use = 4.60 Satisfaction = 4.39 5-May-17 PhD Defense - CIS 59 COMPARATIVE USABILITY 5-May-17 PhD Defense - CIS 60 Usability Test Graph 4.8 4.7 4.6 4.5 4.4 Medical Professional IT Professsional Patients 4.3 4.2 4.1 4 3.9 Completion Time 5-May-17 Easy to Learn Effective Support Error Recovery Comfortability PhD Defense - CIS Easy to Use Satisfaction 61 SUMMARY By this thesis we have been able to: Practically demonstrate the feasibility of using mobile devices such as mobile phones and PDAs in enhancing the effectiveness of health care professionals in the delivery of services to patients Identify the various support services in an eHealth based systems which conform to the treatment process followed by medical professionals in delivery health care delivery. 5-May-17 PhD Defense - CIS 62 SUMMARY Further more, the support services were adequately depicted in a robust software and hardware architecture for easy implementation. Used Wireless Mark-up Language, Java server pages and other tools to provide the required functionalities for the system, while ensuring that the application is usable and deployable across various platforms. 5-May-17 PhD Defense - CIS 63 SUMMARY Move from informal specifications to formal specifications, thus ensuring that ambiguities and incorrectness in specification were tactically handled to guarantee a dependable system adjudge as usable by the end users. Provide a framework for measuring the usability of mobile heath care application by adapting the usability attributes specified by ITU, ISO and ANSI into a seven metrics questionnaire based measurement. 5-May-17 PhD Defense - CIS 64 SUMMARY Finally though, mobile health care application are still at it very early stage of implementation and adoption in Nigeria, the work provide a good specification document that will aid software developers in realizing suitable applications in this domain. 5-May-17 PhD Defense - CIS 65 CONCLUSION In this thesis, we were able to demonstrate the practicability of deploying usable operation support services for care givers and other users in health care sector for the purpose of effective and productive health care delivery in care centres. 5-May-17 PhD Defense - CIS 66 CONCLUSION The support services implemented were formally analyzed and designed to eliminate ambiguities and incorrectness in the product. The application was measured with the usability dimensions suggested by ISO / ANSI / ITU and extended to satisfy to meet the context in a clinic setting and found to have a “good usability” by the potential users of the final product. 5-May-17 PhD Defense - CIS 67 CONCLUSION Finally, the adoption of the product of this research in care centres offers a good contribution for countries to meet the millennium development goals centred on health care by providing an effective IT-based support for care givers. 5-May-17 PhD Defense - CIS 68 PUBLICATIONS [1] Ikhu-Omoregbe N. A., Ehikioya S.A. and Ayo C. K., “Modelling, Design, and Deployment of Mobile Health Care Application” International Journal of Computer Sciences and its Application. (To Appear). [2] Ikhu-Omoregbe N. A., Ehikioya S.A. and Ayo C. K., “A Formal Framework for Deployable Mobile HealthCare Applications”, MEDNET, 11th World Congress on Internet in Medicine, Canada, October, 2006. Available at: {www.mednetcongresss.com} [3] N.A Ikhu-Omoregbe, C. K. Ayo, S.A. Ehikioya, “A Deployable Framework for Mobile Telemedicine Applications”, Medical and Care Compunetics 3, L. Bos et al (Eds.), IOS Press, The Netherlands, 2006, pp. 36-41. Available at: www.booksonline.iospress.nl/Contents/SSSH2Book/Article.aspx? [4] Ikhu-Omoregbe, N.A, Atayero A.A., Ayo, C.K, Olugbara, O.O., “Design and Deployment of Hybrid Telemedicine Applications”, SPIE conference proceedings, Internet Imaging VI, San Jose, U.S.A., 2005, pp 191-196. Available at :www.imaging.org/store/physpub.cfm?seriesid=24&pubid=700 5-May-17 PhD Defense - CIS 69 PUBLICATION/AWARD [5] Ikhu-Omoregbe N. A., Ehikioya S.A. and Ayo C. K., “Implementing Operations Support Systems in E-Health Based Systems, Proceedings of The International Conference & Workshop on 3G GSM & Mobile Computing: An Emerging Growth Engine for National Development, Covenant University, Nigeria, 29-31 January, 2007, pp. 191-198 Microsoft Research Inspire Programme–PhD Proposal Award 2006 (One of six recipients in the world) 5-May-17 PhD Defense - CIS 70 APPRECIATION God – Gift of Life Supervisors Examiners External Examiner University Management and All Staff 5-May-17 PhD Defense - CIS 71 THANK YOU FOR LISTENING & GOD BLESS YOU 5-May-17 PhD Defense - CIS 72